Welcome back to an Introduction to Breast Cancer, I'm Dr. Anees Chagpar. In the previous sessions, we've talked a little bit about surgical management of breast cancer. We've talked about lymph node evaluation and how a lot of things have changed particularly over the last decade or two. We've gone from needing an axillary lymph node dissection on everybody to a sentinel lymph node biopsy followed by an axillary lymph node dissection only if the sentinel lymph node is positive to now, sometimes having a sentinel lymph node biopsy alone, even for patients who have lymph node positive disease. But still, many patients worry about a complication called lymphedema, which is really swelling of the arm. It's a dreaded complication and one that many patients have a lot of questions about. We're going to talk about some of those issues and answer some of those questions. Let's get started. To begin with, lymphedema is one of these things that really is mired between fear and knowledge. A lot of data is available, but a lot of patient's fears are based on anecdote. People worry about the difference between preventing lymphedema and treating lymphedema. And really, don't understand the differences between sentinel lymph node biopsy, which carries a very, very, very low rate of lymphedema and axillary lymph nodes dissection. Regardless, lymphedema still is a complication and many patient are going to ask about it. Let's talk about some of the questions that they frequently get asked. The first, can I exercise or lift weights? What do you think? The answer? Yes. In fact, randomized controlled trials have demonstrated that if you do lift weights your risk of lymphedema actually goes down. This was a great randomized controlled trial of 154 patients that was published in JAMA. A very elite journal that found that if you had more than five lymph nodes removed, so an axillary lymph node dissection for the most part, routine care ended up with a 22% rate of lymphedema. But if you were exercising and particularly lifting weights, your risk of lymphedema was only 7%. So the answer to your questions is get out there and workout. Go to the gym. Can I fly? Should I wear a sleeve when I fly? Does it matter if it's a long trip where I'm going overseas or if I'm just going across the country? The answer is yes, you can fly. And no, you don't need a sleeve. In fact, some studies have actually found that it may be counterproductive. Another great study, this was a study that actually looked at breast cancer survivors who were going for a Dragon Boat Regatta. They were flying, either from Canada to Australia or from one part of Australia to another. So both looking at long haul flights and short haul flights and the newsflash, no difference in lymphedema. They looked at whether patients were wearing sleeves or not, no difference in lymphedema. So the answer is yes, you can fly. You don't need a sleeve, just enjoy your trip. Can I have blood pressures, IV's or blood sticks in that arm? What do you think? Most people would say, no. And that's because most doctors would say, avoid blood pressures, IV's and blood sticks. But I say, maybe. Why? Well, it's quite clear. Blood pressures do increase stasis in that arm and you want to avoid that, especially if you have some swelling. And IV's or blood sticks are portals of infection and you want to avoid that too, particular if you have a lymphadenitis arm, but there are a few caveats that you need to keep in mind. The first is that if you only had a sentinel lymph node biopsy and you haven't had all the lymph nodes removed, they can feel free to do a blood pressure or an IV or a blood stick on that side. Your risk of lymphedema and lymphangitis is really quite low. The other issue and one that I feel very strongly about is MedicAlert bracelets. So a lot of patients say, should I wear a MedicAlert bracelet that says, no IV's, blood pressures or blood sticks in this arm. And to that, my answer is a resounding no. Here's a story, it's actually a true story that happened to me. I was fresh out of fellowship and was practicing in Louisville, Kentucky. I got a phone call from an emergency room physician who was working in a rural part of Kentucky. There had been a terrible car crash. The vehicle was totaled. They needed the jaws of life to extricate this lady and like many trauma patients, she have swollen up like the Michelin man. One arm was broken, they couldn't find an IV anywhere in her legs to start an IV to save her life, but there was a great IV right here. But she had a MedicAlert bracelet and the MedicAlert bracelet said, no IV's, blood pressures or blood sticks in this arm. So the doctor paused and at least he phoned me and said, should I take that IV and start an IV right there and save her life? His concern, of course was that the MedicAlert bracelet was her living will. And so the concern was should he go against her living will if she couldn't verbalize that she wanted him to do so? What I tell my patients is, listen, you want to avoid blood pressures, IVs, and blood sticks. So when you're awake, you can simply say to your doctor, hey, mind using the other side. But if you can't speak, they can put the IV, blood pressure, blood stick, anywhere they want to save your life. It's an easy matter to resolve an infection if you get one afterwards, but it's much better if your life is saved Without having a doctor think twice about whether or not he should start that IV. What about this one? Can I shave? The answer to that is absolutely. There is no data to suggest an increase in lymphedema with shaving. Now of course, you want to avoid cuts if you can and any portals of infection, but it shouldn't prevent you from shaving. What about hand surgery? Let's suppose after your breast cancer surgery, you end up getting carpal tunnel all on the same side. Gosh, what happens then? Well, the answer is of course, you can have hand surgery and there've actually been data to suggest that you really are at no increased risk of lymphedema. In this study, only two out of four patients who had previously had lymphedema had a slight transient worsening, but it got better. So you can feel free to have surgery, as well. Do I need to change my diet? A lot of people ask, what they can do to improve lymphedema? Is it something I ate? Could I change what I do? Well, the answer is maybe. Certainly, we know that weight loss helps. So if you can maintain an ideal body weight, you're increasing your chances of a long and healthy and productive life not mention reducing your chances of lymphedema. But there's no data on low salt intake, which is another key question that many patients ask. So lymphedema is scary. It's understudied. It's a lot less common than people think, especially in an era like it is today where most patients only need a centennial lymph node biopsy. Remember that with a sentinel lymph node biopsy, your risk of lymphedema is well under 2%, so not to worry. Still, I hope that a lot of this information has been helpful to you and to your patients. Until next time, I'm Dr. Anees Chagpar. Thanks for joining me.